Provider Demographics
NPI:1710634977
Name:BROOKS, JAQUAN
Entity Type:Individual
Prefix:
First Name:JAQUAN
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 RIDING TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5924
Mailing Address - Country:US
Mailing Address - Phone:704-685-6370
Mailing Address - Fax:
Practice Address - Street 1:507 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4267
Practice Address - Country:US
Practice Address - Phone:704-232-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0173501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical